/ FIRE INDICATOR PANEL ISOLATION AND DE-ISOLATION PERMIT / Issue Date:01/07/16
ReviewDate:01/07/18
  • Section 1 and 2 To be completed by the person / company who is requesting / requiring the isolation
  • A risk assessment must be undertaken and attached to this permit along with a SWMS
  • The permit and risk assessment will be reviewed by an SHFA Authorised Officer
  • Section 3 to be completed by The Authorised officer of Property along with theFire Protection Impairment Notification and sent to the insurer as required through the Treasury Management Fund – fire impairment notification process.
  • Section 4 is to be completed by the person responsible for isolating and de-isolating the fire panel
  • A copy of this permit must be attached to the FIP while it is isolated.
  • Responsibility for the safety controls listed in the risk assessment remain with the person requesting the isolation

1. Person requesting the isolation / Permit Number
(Building-FIPP-date)
Name of person requesting the isolation /  Tenant
Business Entity
 Contractor / (name)
Signature / Date of submission
Phone number
2. Isolation request details: complete and forward to Property
Building / Level/s / Room/s
Reason for isolation /  Maintenance
 Construction
Requirements (areas marked with* will require insurance company notification / Isolation occurring under the following conditions
Less than 12 hours only, during business hours 6am-1800, less than 20% of building isolated
(ie: daily) /  Yes.  No* / Isolate overnight /  Yes*.  No
Isolate for more than 20% of the building /  Yes.* No / Isolate for more than 12hours
(ie: continuous) /  Yes.* No
Isolation date / De-isolation date
Isolation time / De-isolation time
Indicate days /  Mon.  Tues.  Wed.  Thurs.  Fri.  Sat.  Sun.
3. Authorisation (Facilities Use): / * For isolation: Tresury Managed Fund must be notified under the following conditions >20% building isolated, after hours, more than one day through the Treasury Management Fund – fire impairment notification process.
Name of person authorising the isolation / Use link to the notification form
Certificate number & expiry
Signature / Date of authorisation
Phone number
4. Implementation
Name of person isolating the FIP / Phone Number
Date of isolation
Signature / Time isolated
Name of person
de-isolating the FIP / Phone Number
Date of de-isolation
Signature / Time de-isolated
Custodian: WHS Manager / Uncontrolled copy when printed / ©GPNSW
Approved by: Place Management / Version: 1.0
Number: SMS-02-FM-A1175697 / Page 1 of 1